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16
B. PHYSICAL EXAMINATION
Vital Signs: Temperature: 36.5 oC Pulse Rate: 88 bpm.
Respiratory Rate: 21 cpm Blood Pressure: 150/90 mmHg.
General Observations:
Received patient lying in bed, conscious, coherent and mentally-
oriented to time, people and place. Patient has fair skin with stitches on the
incision site of the lower abdomen. Overall, patient is in a normal
appearance.
Skin: Patient has fair, moist warm and smooth skin. Its turgor is within 1 to 2
seconds.
Hair: Patient has long, black hair. It is distributed evenly. It is smooth and silky.
Scalp: The scalp is free from lesions. Tenderness and masses are not noted.
Nails: Nails of patient are pinkish in color. It is a bit square. It is smooth.
Capillary refill is 2 to 3 seconds. No lesions found.
Skull: Patient has a normocephalic head, symmetrical and no masses were
found.
Face:The face is able to do any impressions or expressions. It is oblong-shaped,
symmetrical and free from edema and/or masses.
17
Eyes: Eyes are functioning properly. No inflammation on the eyelids,
lacrimal glands and other surrounding the eyes. The eyes are wet and moist.
Sclera on both sides is dirty white. Conjuctiva has small blood vessels.
Ears: Ears are symmetrical, fair, and no noted discharge and swelling. The
ears can hear perfectly.
Nose and Sinuses: Nose is symmetrical with no inflammation and
discharges noted. Airway patency is present. Sinuses are palpable and
resonant when percussed.
Mouth and Pharynx: Patient has good breathe. Lips are pinkish and
smooth with moist. Buccal mucosa, gums and tongue are pinkish in color,
teeth are dirty white, and the hard and soft palate are pinkish in color as
well.
Neck: The neck is symmetrical. Lymph nodes are palpable. Bruit sounds are
heard on the trachea. It is felt and palpable. Thyroid gland is palpable. No
inflammation or lesions noted.
Posterior Chest: The posterior chest is symmetrical with the
anteroposterior diameter at a ratio of 2:1. Tenderness and masses are not
found. Thoracic expansion is 2 to 3 cm. vibrations were felt during tactile
fremitus. Resonance upon percussion, and no wheezing or crackling sounds
upon auscultation.
18
Anterior Chest: Pulsations are felt. No wheezing or crackle sounds are
heard upon auscultation.
Heart: Heart is positioned right and correctly with the cardiac landmarks.
Heartbeats are heard during auscultation.
Vascular System: Carotid arteries are present with pulsations felt. It is
palpable and no lumps are felt. Blood pressure is within normal range.
Lymphatic system: Epitochlear nodes are palpable, as well as, the
superficial inguinal nodes. No tenderness noted.
Breast: The breasts are big due to lactation. There are no dimplings, nipple
discharges, tenderness nor lumps noted. Patient is aware of breast self-
examination and learned it.
Abdomen: Abdomen is round. The umbilicus is inverted. Respiration and
surface motion are present. Pulsations on the abdomen are felt. The
abdomen is palpable.
Female External Genitalia and Anus: Patient has stitches on her
perineum.
Musculoskeletal System: Patient has grip strength. Temporomandibular
joint is felt. The neck, shoulder, hip, spine, knees, feet, ankles, hands, elbow
and wrists can do the different ranges of motion easily.
19
Deep Tendon Reflexes: Biceps, triceps, Brachioradialis, patellar, Achilles
and plantar reflexes are present.
Neurologic Screening Assessment: Patient is conscious, coherent and
alert. She has good memory and is mentally-oriented with people, place and
time. She has goos speech patterns and walks properly.
Cranial Nerves Assessment
Cranial Nerve
Function Method Client’s Responses
I Olfactory
Smell reception and interpretation
Ask client to close eyes and identify different mild aromas such alcohol, powder and vinegar.(Weber & Kelley; 2011).
The Client is able to distinguish different smells
II Optic Visual acuity and fields
Ask client to read newsprint and determine objects about 20 ft. away (Weber & Kelley; 2011).
The Client is able to read newsprint and determine far objects
III Oculomotor
Extraocular eye movements, lid elevation, papillary constrictions lens shape
Assess ocular movements and pupil reaction(Weber & Kelley; 2011).
The Client is able to exhibit normal EOM and normal reaction of pupils to light and accommodation
IV Trochlear
Downward and inward eye movement
Ask client to move eyeballs obliquely(Weber & Kelley; 2011).
The Client is able to move eyeballs obliquely
V Trigemi Sensation of Elicit blink reflex by The Client blinks
20
nal face, scalp, cornea, and oral and nasal mucous membranes. Chewing movements of the jaw
lightly touching lateral sclera; to test sensation, wipe a wisp of cotton over client’s forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensation
Assess skin sensation as of ophthalmic branch above
Ask client to clench teeth(Weber & Kelley; 2011).
whenever sclera is lightly touched; able to feel the wisp of cotton over the area touched; able to discriminate blunt and sharp stimuli
The Client is able to sense and distinguish different stimuli
The Client is able to clench teeth
VI Abducens
Lateral eye movement Ask client to move
eyeball laterally ( Weber & Kelley; 2011).
The Client is able to move eyeballs laterall
VII
Facial Taste on anterior 2/3 of the tongueFacial movement, eye closure, labial speech
Ask client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffee(Weber & Kelley; 2011).
The Client is able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty and bitter taste
VIII
Acoustic Hearing and balance
Assess client’s ability to hear loud and soft spoken words; do the watch tick test (Weber & Kelley; 2011).
Client is able to hear loud and soft spoken words; able to hear ticking of watch on both ears
IX Glossop Taste on Apply taste on Client is able to
21
haryngeal
posterior 1/3 of tongue, pharyngeal gag reflex, sensation from the eardrum and ear canal.Swallowing and phonation muscles of the pharynx
posterior tongue for identification (sugar, salt and coffee); ask client to move tongue from side to side and up and down; ask client to swallow and elicit gag reflex through sticking a clean tongue depressor into client’s mouth(Weber & Kelley; 2011).
identify different tastes such as sweet, salty and bitter taste; able to move tongue from side to side and up and down; able to swallow without difficulty, with (+) gag reflex
X Vagus Sensation from pharynx, viscera, carotid body and carotid sinus
Ask client to swallow; assess client’s speech for hoarseness (Weber &Kelley; 2011).
The Client is able to swallow without difficulty; has absence of hoarseness in speech
XI Spinal accessory
Trapezius and sternocledomastoid muscle movement
Ask client to shrug shoulders and turn head from side to side against resistance from nurse’s hands (Weber & Kelley; 2011).
The Client is able to shrug shoulders and turn head from side to side against resistance from nurse’s hands
XII
Hypoglossal
Tongue movement for speech, sound articulation and swallowing
Ask client to protrude tongue at midline, then move it side to side(Weber & Kelley; 2011).
The Client is able to protrude tongue at midline and move it side to side
Janet Weber & Jane Kelley; 2011
IV. ANATOMY AND PHYSIOLOGY
22
A. External Structures:
1. Mons Veneris/Pubis – Pad of fat which lies over the symphysis pubis
where dark and curly hair grow in triangular shape that begins 1-2 years
before the onset of menstruation. It protects the surrounding delicate
tissues from trauma. (Marieb; 2011).
2. Labia Majora – Two (2) lengthwise fatty folds of skin extending from
mons veneris to the perineum that protect the labia minora, urinary meatus
and vaginal orifice. (Marieb; 2011).
3. Labia Minora – 2 thinner, lenghtwise folds of hairless skin extending
from clitoris to fourchette (Marieb; 2011).
Glands in the labia minora lubricates the vulva
23
4. Very sensitive because of rich nerve supply Space between the labia is
called the Vestibule (Marieb; 2011).
5. Clitoris – small, erectile structure at the anterior junction of the labia
minora that contains more nerve endings. It is very sensitive to
temperature and touch, and secretes a fatty substance called Smegma. It
is comparable to the penis in it’s being extremely sensitive (Marieb; 2011).
6. Vestibule – the flattened smooth surface inside the labia. It encloses the
openings of the urethra and vagina. (Marieb; 2011).
7. Skene’s Glands/Paraurethral Glands – located just lateral to the
urinary meatus on both sides. Secretion helps lubricate the external
genital during coitus. (Marieb; 2011).
8. Bartholin’s Gland/Vulvovaginal Glands – located lateral to the vaginal
opening on both sides. It lubricates the external vulva during coitus and
the alkaline pH of their secretion helps to improve sperm survival in the
vagina. (Marieb; 2011).
9. Fourchette – thin fold of tissue formed by the merging of the labia
majora and labia minora below the vaginal orifice. (Marieb; 2011).
10. Perineum – muscular, skin-covered space between the vaginal
opening and the anus. It is easily stretched during childbirth to allow
24
enlargement of vagina and passage of the fetal head. It contains the
muscles (pubococcygeal and levator ani) which support the pelvic organs,
the arteries that supply blood and the pudendal nerves which are
important during delivery under anesthesia. (Marieb; 2011).
11. Urethral meatus – external opening of the urethra. It contains the
openings of the Skene’s glands which are often involved in the infections
of the external genitalia. (Marieb; 2011).
12. Vaginal Orifice/Introitus – external opening of the vagina, covered
by a thin membrane called Hymen. (Marieb; 2011).
B. Internal Structures:
25
1. Fallopian tube/Oviduct – 4 inches long from each side of the uterus
(fundus). It transports the mature ova form the ovaries to the uterus and
provide a place for fertilization of the ova by the sperm in it’s outer 3rd or
outer half. Parts: (Marieb; 2011).
Interstitial – lies within the uterine wall
Isthmus – portion that is cut or sealed in a tubal ligation.
Ampulla – widest, longest portion that spreads into fingerlike
projections/fimbriae and it is where fertilization usually occurs.
26
Infundibulum - rim of the funnel covered by fimbriated cells
(hair covered fingerlike projections) that help to guide the ova
into the fallopian tube. (Marieb; 2011).
2. Ovaries – Oval, almond sized, dull white sex glands on either side of the
uterus that measures 4 by 2 cm in diameter and 1.5 cm thick. It is
responsible for the production, maturation and discharge of ova and
secretion of estrogen and progesterone. (Marieb; 2011).
3. Uterus – hollow, pear-shaped muscular organ, 3 inches long, 2 inches
wide, weighing 50-60 grams held in place by broad and round ligaments, and
abundant blood supply from the uterine and ovarian arteries. It is located in
the lower pelvis, posterior to the bladder and anterior to the rectum. Organ
of menstruation, site of implantation and provide nourishment to the
products of conception. (Marieb; 2011).
Layers:
1. Perimetrium – outermost layer of the uterus comprised of connective
tissue, it offers added strenght and support to the structure. (Marieb; 2011).
2. Myometrium – middle layer, comprised of smooth muscles running in
3 directions; expels fetus during birth process then contracts around
blood vessels to prevent hemorrhage. (Marieb; 2011).
3. Endometrium – Inner layer which is visibly vascular and is shed
during menstruation and following delivery. (Marieb; 2011).
Divisions of the Uterus:
27
1. Fundus – upper rounded, dome-shaped portion that can be palpated to
determine uterine growth during pregnancy and the force of contractions
and for the assessment that the uterus is returning to it’s non-pregnant
state following child birth. (Marieb; 2011).
2. Corpus – body of the uterus. (Marieb; 2011).
3. Isthmus – area between corpus and cervix which forms part of the
lower uterine segment. It enlarges greatly to aid in accommodating the
fetus. The portion that is cut when a fetus is delivered by a caesarian
section. (Marieb; 2011).
4. Cervix – lower cylindrical portion that represents 1/3 of the total
uterus. Half of it lies above the vagina; half of it extends to the vagina.
(Marieb; 2011).
5.Vagina – a 3-4 inch long dilatable canal located between the bladder
and the rectum, it contains rugnae which permit considerable stretching
without tearing. It acts as a organ of intercourse/copulation and
passageway for menstrual discharges and fetus. (Marieb; 2011).
V. CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF
PREGNANCY
Sexual intercourse
MALE FEMALE
28
Release of FSH by the anterior Pituitary Gland
Development of the graafian follicle
Production of estrogen(thickening of the endometrium)
Release of the Luteinizing Hormone
Ovulation
(release of mature ovum from the graafian follicle)
Ovum travels into the graafa tube
Fertilization
(union of the ovum and sperm in the ampulla)
Zygote travels from the fallopian tube to the uterus
Implantation
Development of the fetus/ embryo and placental structure until full term
Preliminary signs of labor
29
Lightening Braxton Hicks Contraction Ripening of the cervix
(descent of the fetal wherein (or false labour or practice (the softened, effaced andhead into the pelvis softer like contractions) dilated condition of the earlobe) cervix just prior to labor)
True labor
Uterine contractions Show Rupture of the membranes
(at regular intervals that begin (After the discharge of the mucous (rupture of the amniotic sac at the onset before the fetus is mature, plug that has filled the cervical canal of, or during, labor.) usually before the due date during pregnancy, the pressure of delivery) of the descending presenting part of the fetus causes the minute capillaries in the cervix to rupture. )
Pregnant woman with blood pressure higher than 140/90 mmHg
Before 20 weeks Gestation After 20 weeks
Gestation
No/stable Proteinuria increase blood pressure Proteinuria No Proteinuria/ HEELP syndrome
Preeclampsia Gestational HPN
Preeclampsia
Eclampsia
30
VI . EXPLANATION OF THE PATHOPHYSIOLOGY OF THE DISEASE
CONDITION / SYMPATHOMATOLOGY
The current concepts regarding the pathophysiology of eclampsia
recognize that eclampsia is a multisystem disorder characterized by
vasoconstriction, metabolic changes, endothelial dysfunction, and
activation of the coagulation cascade in conjunction with an
inflammatory response. Women with underlying microvascular disease,
such as diabetes, hypertension, and collagen vascular disease, have a
higher incidence of eclampsia.
Normal placental development involves progressive loss of the
musculoelastic tissue in the spiral arteries that feed the vessels of the
intervillous spaces, which results in uterine blood flow increases of nearly
25% during the first trimester. This process of remodeling the maternal
spiral arteries that branch from the uterine artery is typically
completed by 18-20 weeks' gestation.
This physiologic dilatation of the spiral arteries does not occur
because the placental trophoblast cells do not invade the spiral arteries,
resulting in maintenance of narrow vessels with resultant placental
hypoperfusion and ischemia. In severe cases, not only do the spiral arteries
maintain their muscular structure, but other pathologic changes also
occur. Accumulation of fat-laden macrophages with fibrinoid necrosis (ie,
acute atherosis), disruption of the basement membranes, platelet
31
deposition, mural thrombi, and proliferation of intimal and smooth muscle
cells all decrease the luminal diameter.
The narrowed and damaged spiral arteries become thrombosed,
resulting in placental infarction and necrosis. Uteroplacental blood flow is
then reduced by 50-75%. The anatomical reduction in blood flow may be
complicated by vasospasm of the uteroplacental bed.
The primary defect in preeclampsia appears to originate at the
maternal-fetal interface (the placenta). Decreased placental perfusion is
thought to lead to fetoplacental ischemia. The ischemic placenta may
produce circulating antiangiogenic factors that promote generalized
maternal vascular endothelium dysfunction, leading to systemic
manifestations of preeclampsia. Associated abnormalities in clotting and
platelet function contribute to vasoconstriction and platelet adhesion and
aggregation, as well as to the activation of coagulation factors that
increase the risk of thromboembolic formation.
The primary feature of clampsia, development of hypertension, occurs
when normally extreme vasodilatation does not occur. Although cardiac
output increases 30-50%, the decreased peripheral vascular resistance
(PVR) results in decreased BP, even in women with chronic hypertension.
Women who develop preeclampsia experience an increase in PVR and
alterations in vascular sensitivity to endogenous hormones (eg,
angiotensin II, catecholamines, vasopressin). This increase in vascular
32
reactivity to pressor hormones may be mediated, at least in part,
through damage to vascular endothelial cells, disrupting the normal
prostaglandin balance.
The normal expansion of blood volume by 50% that occurs with
pregnancy is decreased by 15-20% in patients with preeclampsia. This
is the result of diminished plasma volume, leading to the relative
hemoconcentration observed in preeclampsia. The plasma volume
abnormality involves a redistribution of extracellular fluid, such that
interstitial fluid volume is increased while the plasma volume is
decreased. The hematocrit increases as the severity of preeclampsia
increases. Circulating blood volume is maintained by the increased
vascular tone.
(Pillitteri; 2011)
33
VII. CLINICAL MANAGEMENT
A. MEDICAL MANAGEMENT
A.1 LABORATORY AND DIAGNOSTIC EXAMINATIONS
Diagnostic orLaboratory
Procedure
Indication orPurpose
Results NormalValues
Analysis andInterpretation
of Results
WBC CountTo determine
infection orInflammation Pre-operation
Assessment of the patient.
19.5 H 108/L 3.5-10.0 H No infection orinflammation
is present.
RBC CountPre-operation
assessment ofThe patient.
4.23 1012/L 3.80-5.80Decreased RBC count on
pregnant is normalbecause of the increase
inplasma volume during
pregnancy.
Hemoglobin
Pre-operation assessment of
the patient.
133 g/L 110-165 L g/L
The result indicates that a1000 ml sample of
blood contains 96 g ofhemoglobin. Decreased hemoglobin on pregnant
isnormal because of their
increase in plasma.
Hematocrit Pre-operation
assessment of
.
366 L 1/1 .350-.500 L 1/1
The result indicates that a1000 ml sample of
blood contains .29 g of
34
the patient. hemoglobin. Decreasedhematocrit on pregnant isnormal because of their
increasein plasma volume.
URINALYSIS
TEST NAME RESULT SIGNIFICANCE
MACROSCOPIC
color
pH
protein
glucose
MICROSCOPIC
RBC
WBC
Epithelial cells
Mucus Threads
Amorphous
material
Bacteria
Yellow
6.0
(+)
(-)
0-1
0-2
Few
Few
Few
Few
Normal
Normal
High
Low
Low
Low
Low
Low
Low
Low
35
A.2 Treatment and Procedures
1. Vitals Signs Taking
vital signs will be continually monitored while recovering. The Client’s
Respiratory rate, Pulse rate, blood pressure, and temperature are typically
tracked while recovering. (Pillitteri; 2011).
2. Intake and Output Monitoring
Intake Is any measurable fluid that goes into the patient's body. Intake
includes fluids (such as water, soup, and fruit juice) and "solids" composed
primarily of liquids (such as ice cream and gelatin) that are taken by mouth
(orally), fluids that are introduced by IV, and fluids that are introduced by
irrigation (through a tube) (Pillitteri; 2011).
Output Is any measurable fluid that comes from the body. Water given off in
the form of perspiration and water vapor (exhaled breath) is also output, but
it is not recorded on the DD Form 792, since it cannot be accurately
measured. (An adult usually looses about 500 milliliters (ml) a day through
perspiration and moisture exhaled in breathing.) The major forms of output
36
recorded on the worksheet are urine, drainage, vomitus (matter vomited),
and stools (fecal discharge from the bowels). (Pillitteri; 2011).
3. Perineal Care
Cleaning of perineum and the materials it uses is inb accordance to the
policy of the institution. In SVGH, the perineum is clean with lukewarm water
and an antiseptic agent like betadine solution before birth. Following delivery
of the placenta, the perineal area of the mother is washed with tap water as
vaginal canal is clean manually. (Pillitteri; 2011).
4. Delivery
Before the cesarean section procedure, the patient was given anesthesia to
numb the pain. The doctor then made horizontal incision in the abdomen and
uterus. After the incision was made, the baby was delivered through it, and
the placenta was removed. After the cesarean section procedure, the
incision was closed with stitches. When the cesarean section was started, the
doctor made a 6- to 8-inch incision in the abdomen directly over the uterus.
The incision was horizontal, which was side to side. The baby was then
delivered through this opening. (Pillitteri; 2011).
37
5. New born Care
The umbilical cord was cut, and the baby was handed to the healthcare
provider, who took him to a small, warmly lit plastic crib called a warmer.
Then the baby was cleaned and dried and eventually checked by the
pediatrician.
After the baby had been delivered, the placenta was carefully removed from
the uterus. At that time, the patient received oxytocin, a drug that causes the
uterus to contract and helps prevent serious bleeding. The doctor then closed
the incision on the uterus, and the incisions in the skin were closed with
stitches that would dissolve on their own. (Pillitteri; 2011).
A.3 Medications
See Appendix E
A.4 DIET
1. NPO
After the surgery the doctor ordered the NPO diet. NPO is a type of diet
people are placed on by their medical professionals. A NPO diet is most often
seen in a hospital setting. Some patients can be placed on a NPO diet for just
a short time while others may have to stay on it for a much longer time.
38
Patient cannot have anything that would go in the mouth including food,
beverages and oftentimes medications. Patient can be made NPO for a
variety of reasons including an upcoming surgery, medical procedure or test.
She cannot have anything to eat or drink prior to surgery to honoring the NPO
status is very important.
2. Clear Liquid/ General Liquid
Patient is on a clear liquid diet consists of clear liquids, such as water and plain
gelatin, that are easily digested and leave no undigested residue in your intestinal
tract. The doctor may prescribe a clear liquid diet before certain medical
procedures or have certain digestive problems. Because a clear liquid diet can’t
provide with adequate calories and nutrients, it shouldn’t be continued for more
than a few days. A clear liquid diet is often used before tests, procedures or
surgeries that require no food in the stomach or intestines, such as before
colonoscopy.
BREAKFAST ½ cup of oatmeal & 1 glass of milkLUNCH ½ cup of corn soup & 1 glass of waterDINNER ½ cup of chicken soup & 1 glass of juice
3. Soft Diet
After the clear liquid the doctor ordered a soft diet. A soft diet is recommended
in many situations, including surgery involving the mouth or gastrointestinal tract,
and pain from newly adjusted dental braces. A soft diet can include many foods if
they are mashed, pureed, combined with sauce or gravy, or cooked in soups, chili,
or curries.
BREAKFAST 1 cup of rice, 1 bacon & 1 glass of milkLUNCH 1 cup of rice, 1 serving of chicken soup, 1 banana & 1 glass of
waterDINNER 1 cup of rice, I serving of vegetable soup with 1 ripe of mango &
1 glass of water
39
4. Full Diet
After the soft diet, the patient is ordered DAT. Diet is tolerated is a term that
indicates that the gastrointestinal tracts is tolerating food and is ready for
achievement to the next stage. Therefore, this statement is most effectively in
regard to the diet after abdominal or gastrointestinal surgery, signifying the
patient’s wellness of her diet.
BREAKFAST 1 cup of rice, 1 hotdog & 1 cup of milkLUNCH ½ of rice, 1 slice of meat, & glass of juiceDINNER ½ cup of rice, 1 fish, & glass of water
B. NURSING MANAGEMENT
B.1 Nursing Care Plan
See Appendix C
B.2 Discharge Plan
See Appendix D
ACTUAL CARE GIVEN
1. Vitals Signs Taking
Monitoring of vital signs was done every shift, intake and output
measurement were not strict operating procedure yet we were required t
monitor the client’s intake and output.
2. Administration of Medication
Medications were administered via oral route TID as prescribed by the
physician with a full stomach to decrease GI upset.
3. Bedside Care
40
Giving optimal health both to the mother and client served as our goal as we
performed some nursing interventions like promoting a conducive
environment through bedmaking and adjusting the room temperature. We as
well assisted the client with her needs such as changing of position and
guiding her as she walked.
4. Health Teaching
As a health care provider, I discussed the concept of Family Planning to the
client and gave her information on the proper newborn care & the
importance of proper nutrition and exercise to promote health and
prevention of disease
See Appendix F
PROBLEMS ENCOUNTERED DURING THE CARE
The patient was very cooperative as I deal with her. She was a bit shy and
aloof at first but as the establishing rapport progresses she was able to
manage the timidity and shared her predicaments of pregnancy and
delivery. When I was about to give the medications due for 6pm. I wasn’t
able to do it on time for the client never had her lunch yet. She was still
waiting for her SO to arrived whom brought her meals. For 2 days of nursing
41
care, there were no aberration present; hence, nursing care was done
spontaneously.
IX. CONCLUSION AND RECOMMENDATION
Conclusion
Nurses can help the nation achieve National Health Goals. These goals
speak directly to both fetus and the mother because pregnancy is a high risk
factor for them. Close monitoring in pregnant women and health teaching as
much as possible about pregnancy could definitely reduce life threatening
complications.
Studies show that there is no certain facts that will give us the idea
where Eclampsia arise. But there so many factors that could prevent this
complication such as diet modifications, proper compliance with the health
care providers, proper exercise. And if the complication is already present,
proper monitoring, proper diet and drug compliance should be ruled in.
42
The main purpose of the study was successfully met. The major
reason why the patient underwent a surgical procedure called LSTCS was
due to Eclampsia. The baby exhibited non-recessing fetal heart tone as
uterine contractions occur. The operation was done to resolve the risk of
pregnancy and eventually save the baby’s life.
Further run through of the study showed that there are many
other complications that would pose a risk to pregnant women. These were
more complicated and rare. Unlike those, Pre-eclampsia are seen most
commonly in pregnant women experiencing labor.
Recommendation
As a nursing student, it is a responsibility to give a pregnant patient
the proper recommendation so she can make herself ready if any problem
will arise. She should be monitored frequently—her blood pressure, medical
history and also check the baby inside if he/she is doing well or in the proper
position. The most important one is the mother’s health. The mother should
be given the proper care for herself and for the baby. There is a possibility
that a caesarean delivery might be planned advance if a medical reason is
needed or it might be unplanned and take place during the labor if some
problems occur.
The mother must be given the proper knowledge regarding a vaginal
or caesarean delivery right from her first pregnancy. For caesarean section,
43
it is very complicated operation which can have some risks like death for the
mother, sometimes have some initial trouble breathing for the newborn
babies and will make them drowsy from the pain medication administered to
the mother. Breastfeeding maybe difficult due to the limited mobility of the
mother after the operation. A pregnant woman must be well cared by a
nurse with her personal attending obstetrician.
With this study, the student nurses were able to gain more knowledge
and wider view and perspective of the complication of pregnancy which is
Eclampsia. Thus, the student nurses would like recommend and share some
pointers on how to deal with different diseases with pregnancy specifically
Eclampsia.
To the health care team, they should righteously implementing basic
and ideal procedures regardless of the health care facilities where they
belong. They must observe and always remember to keep in line with their
duties towards both the mother and the child during the pregnancy.
X. IMPLICATIONS OF THE STUDY TO
A. Nursing Education
This study helps in enriching the knowledge base of the nurses
regarding the concepts of this kind of complication. This would greatly help
in determining the risk factors that would possibly be prevented from
44
occurring once there is an application of this study. This can cater all the
questions regarding how and why this certain kind of operation is performed.
The best thing about this study is that there is a comprehensive explanation
of the relationship between the surgery performed and the cause of this
high-risk pregnancy. The cause is highly fatal if not given attention so this
gave motivation to performing CS. This broad information would really
enhance the previously learned concepts of the nurse so as to help him/her
in becoming a competent nurse.
B. Nursing Practice
This study helps in giving care to a woman experiencing high-risk
pregnancy. Appropriate measures and interventions can be taken which are
very useful in promoting the health status of the client. The nurse’s skills are
further guided as to how he/she manages the implementation of nursing
procedures in order to meet the varying needs of his/her patient. This study
alarms the nurses when to act immediately in cases of unexpected or
unusual situations which might pose a risk to the mother or the baby or
maybe both. Having competency in performing the procedures is the most
effective way of responding the needs of the client. That is why this study is
45
equipped with numerous appropriate and effective interventions that would
somehow guide and develop the nurse in his/her nursing practice.
C. Nursing Research
As it is a comprehensive compilation, this study greatly helps in the
development of nursing profession. It typically shows how an individual was
able to cope up with this kind of complication. As we all know, each
individual has a unique adaptive mechanism. This study gives relevant
contribution to modern studies at it is of a high-technologically based study.
Modern facilities are used in the performance of care to the patient,
monitoring and as well as the operation. Moreover, there is a good
complementation since the patient is at high risk. It shows the beneficial
relationship of our technological advances to science nowadays. This study
will further be a basis of improving the nursing approach to high-risk
pregnancies.
BIBLIOGRAPHY
Book Sources:
Doenges, Marilyn E., et al. Nurse’s Pocket Guide. 7th edition. F.A. Davis
Company, Philadelphia, 2009.
Kozier et al Fundamentals of Nursing: Concepts, Processes, and Practice. 5th
ed. Addison – Wesley Publishing Co. Inc.
46
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family. 6th ed. Lippincott Williams and Wilkins, 2008
Tate, P., et al Seeley’s Principles of Anatomy & Physiology. McGraw-Hill
Companies, Inc., 2009
Internet Sources:
www.nursingcrib.com/nursing-notes-reviewer/ectopicpregnancy/
Retrieved (March19, 2012)
www.wikipedia.com/eclampsia/pregnancy/
Retrieved (March 20, 2012)